Cardiology on call

ACS, arrhythmias, heart failure and BP emergencies in CCU and the cardiology ward.

• Acute coronary syndrome (heart attack)ECG within 10 minutes. STEMI: primary PCI if it can happen within 120 minutes, otherwise thrombolysis within 30 minutes of arrival. NSTEMI: antiplatelets, anticoagulation and risk-guided angiography.
• Atrial fibrillationUnstable means shock it. Stable means control the rate, treat the trigger and decide about anticoagulation. Rheumatic mitral stenosis means warfarin, not a DOAC.
• Fast heart rhythms (SVT, VT and others)Unstable means synchronised shock. Stable means read the ECG: narrow or broad, regular or irregular. Adenosine for regular narrow SVT, amiodarone for VT, and treat sinus tachycardia's cause, not the rate.
• Bradycardia and heart blockSlow pulse with shock, fainting, chest pain or heart failure needs atropine now. If it fails, or the rhythm is high-risk, pace. Always check potassium and the drug chart.
• Acute heart failure and pulmonary oedemaSit the patient up, give oxygen, IV furosemide, GTN if the BP is high enough, and CPAP if still hypoxic. Then find out why the heart failed today.
• Hypertensive emergencyHigh BP alone is not an emergency. Look for organ damage. Emergency: IV treatment in a monitored bed, lowering MAP by no more than 25% at first. Urgency: oral tablets and follow-up.
• Chest pain on the wardThe staff nurse calls about chest pain. Ask for an ECG now, go and see the patient, and think ACS, PE, dissection and pneumothorax.
• Fast heart rate on the wardNarrow or broad, regular or irregular, any adverse features? And is it just sinus tachycardia from bleeding, sepsis, pain or dehydration?